When Patients Don’t Follow their Medication Regimen

The warnings are impressive for those people who are naughty and do not take medications as prescribed:

Medication non-compliance (non-adherence), the failure to take drugs on time in the dosages prescribed, is as dangerous and costly as many illnesses

Drugs don’t work in patients who don’t take them

— C. Everett Koop, MD

10% of hospital admissions are due to drug noncompliance

Well, how many hospital admissions are due to somebody who did take medication as ordered and suffered a bad reaction? According to the Drug Abuse Warning Network (DAWN) Report, a public surveillance system, over 1 million people over age 50 landed in the emergency room in 2008 from bad reactions to medications. How high might that number have been if the “naughty” patients did take their medication too?

And consider the impressive array of medication-taking aids: colorful organizers, email reminders, 6-alarm watch, digital pill dispensers, multi-alarm pill organizers. I’m waiting for a “personal pill secretary” to jump out of a pill gadget but I won’t hold my breath.

Seems like an open and shut case of ‘patient mischief’ for those rebels who neglect to follow doctor’s advice to the letter. And the punishment? Well, not so fast…..

Could it be a good thing when patients disobey direct orders from their healthcare providers? What are the reasons behind noncompliance with taking medication? Before we lock up these medication miscreants and rebels, let us consider what lies beneath the surface. Are there logical and reasonable reasons for medication revolt? Consider the following:

  • Perhaps that medication is causing the patient vague side effects such as weakness or drowsiness or fogginess? “Just not feeling right.”
  • Maybe that new medicine is interacting with the five other medications that person is taking to cause general feelings of not being well?
  • Is the doctor the problem? Did the doctor take enough time to explain how to take the new drug? Common side effects? What to avoid? Time of day to take the drug, with or without food? Did the doctor prescribe too high a dose for a drug-sensitive patient or an older adult? “Start low and go slow” is a wise approach to prescribing necessary drugs. Has your doctor prescribed an untested “designer” (newly approved) drug because of pharmaceutical promotion pressures? Maybe non-drug treatments could work as well?
  • Perhaps that medication is causing a specific side effect that is troublesome such as sexual performance problems or depression? No wonder that person stopped the medication!
  • Is that newly added medication simply too expensive and straining the budget to the point of medication versus meals?
  • Is the patient overwhelmed taking 10 to 20 pills every day? Maybe complexity is causing a person to forget some medications? Could it be frustration and rebellion? Or a case of doing the doctor’s job  – regimen simplification and reevaluation which should be done every 6 to 12 months.
  • Has the doctor discussed non-drug options for treatment? Perhaps a glass of beet-root juice daily, exercise and a low salt diet will work as well as that blood pressure pill – with fewer side effects!
  • Some patients may simply be frustrated with the sick role — taking many medications for their many illnesses while still being told by their doctor, “You aren’t doing enough to get your blood pressure down, your blood sugars lower and your weight reduced.” It’s enough to get you down!
  • Is your doctor running up a “prescribing cascade” in which drug #1 causes depression as a side effect, for example, so several weeks later your doctor prescribes drug #2 to treat your depression. In fact, the first medication should have been stopped.
  • Maybe the “disease” is the problem. Why isn’t your blood pressure low enough on four different pressure medications, for instance? Has your doctor stressed diet and lifestyle treatments? Has your doctor tested you for rarer medical causes? Have you been checked for “end-organ” damage? With high blood pressure, for example, true hypertension causes actual signs of early damage like protein in urine or thickening of the heart – called end-organ damage. Heart disease and stroke are the final extremes of that damage. It is not unusual for elders to have a blood pressure of 154 but no mounting signs of actual organ damage. Lowering the pressure to an ‘ideal’ 120 might do nothing to stave off disease, but might cause dizziness and weakness, especially when standing up.

While I do not advocate throwing all prescribed medications to the bottom of the sea as Oliver Wendell Holmes suggested, I do recommend careful thought and discussion with your doctor before taking any medication. It is time to stop labeling patients as “noncompliant” and defiant when they stop taking a medication. If properly explored, there often will be reasonable and justifiable explanations when someone stops a prescribed drug. Doctors should not reflexively point fingers; rather look more closely at their prescribing habits to determine if that prescription is, in fact, the best treatment and best drug at the lowest effective dose.

Reminder: First try non-drug treatment alternatives. Be sure your medication is the safest option and is being prescribed for the right reasons and with likelihood of significant benefits. Be aware that more drugs equals more risk for bad reactions, including potentially serious side effects that require hospitalization. The elderly are at greatest risk because, with aging, the liver and kidneys no longer process drugs and toxins as efficiently.

Sources

  1. Friedman, O et al. Antihypertensive Drug Persistence and Compliance Among Newly Treated Elderly Hypertensives in OntarioThe American Journal of Medicine - Volume 123, Issue 2 (February 2010)
  2. Heard, K, MD. Inappropriate prescribing in elderly ED patients. American Journal of Emergency Medicine - Volume 26, Issue 3 (March 2008).
  3. Krousel-Wood, M. MD. Barriers to and Determinants of Medication Adherence in Hypertension Management: Perspective of the Cohort Study of Medication Adherence Among Older Adults. Medical Clinics of North America - Volume 93, Issue 3 (May 2009)
  4. Pham, C.B. et al. Minimizing Adverse Drug Events in Older Patients. American Family Physician - Volume 76, Issue 12 (December 2007).
  5. Prybys, KM, DO. Deadly drug interactions in emergency medicine. Emergency Medicine Clinics of North America - Volume 22, Issue 4 (November 2004).
  6. The DAWN Report (February 24, 2011). http://www.oas.samhsa.gov/2k11/DAWN013/AdverseReactionsOlderAdults_HTML.pdf